Gabriel David Sundararaj

Role of posterior stabilisation in the management of tuberculosis of the dorsal and lumbar spine

We present a prospective study of patients with tuberculosis of the dorsal, dorsolumbar and lumbar spine after combined anterior (radical debridement and anterior fusion) and posterior (instrumentation and fusion) surgery. The object was to study the progress of interbody union, the extent of correction of the kyphosis and its maintenance with early mobilisation, and the incidence of graft and implant-related problems. The American Spinal Injury Association (ASIA) score was used to assess the neurological status. The mean preoperative vertebral loss was highest (0.96) in the dorsal spine. The maximum correction of the kyphosis in the dorsolumbar spine was 17.8 degrees. Loss of correction was maximal in the lumbosacral spine at 13.7 degrees. All patients had firm anterior fusion at a mean of five months. The incidence of infection was 3.9% and of graft-related problems 6.5%. We conclude that adjuvant posterior stabilisation allows early mobilisation and rehabilitation. Graft-related problems were fewer and the progression and maintenance of correction of the kyphosis were better than with anterior surgery alone. There is no additional risk relating to the use of an implant either posteriorly or anteriorly even when large quantities of pus are present.

Treatment of haematogenous pyogenic vertebral osteomyelitis by single-stage anterior debridement, grafting of the defect and posterior instrumentation

Anterior debridement, grafting of the defect and posterior instrumentation as a single-stage procedure is a controversial method of managing pyogenic vertebral osteomyelitis. Between 1994 and 2005, 37 patients underwent this procedure at our hospital, of which two died and three had inadequate follow-up. The remaining 32 were reviewed for a mean of 36 months (12 to 66). Their mean age was 48 years (17 to 68). A significant pre-operative neurological deficit was present in 13 patients (41%). The mean duration of surgery was 285 minutes (240 to 360) and the mean blood loss was 900 ml (300 to 1600). Pyogenic organisms were isolated in 21 patients (66%). All patients began to mobilise on the second post-operative day. The mean hospital stay was 13.6 days (10 to 20). Appropriate antibiotics were administered for 10 to 12 weeks. Early wound infection occurred in four patients (12.5%), and late infection in two (6.3%). At final follow-up, the infection had resolved in all patients, neurological recovery was seen in ten of 13 (76.9%) and interbody fusion had occurred in 30 (94%). The clinical outcome was excellent or good in 30 patients according to Macnabs criteria. This surgical protocol can be used to good effect in patients with pyogenic vertebral osteomyelitis when combined with appropriate antibiotic therapy.

Long-term outcome of high-energy open Lisfranc injuries: a retrospective study.

BACKGROUND The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different? METHODS We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years). RESULTS According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present. CONCLUSION In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

The use of titanium mesh cages in the reconstruction of anterior column defects in active spinal infections: can we rest the crest?

Study Design Retrospective clinical series. Purpose To assess whether titanium cages are an effective alternative to tricortical iliac crest bone graft for anterior column reconstruction in patients with active pyogenic and tuberculous spondylodiscitis. Overview of Literature The use of metal cages for anterior column reconstruction in patients with active spinal infections, though described, is not without controversy. Methods Seventy patients with either tuberculous or pyogenic vertebral osteomyelitis underwent a single staged anterior debridement, reconstruction of the anterior column with titanium mesh cage and adjuvant posterior instrumentation. The lumbar spine was the predominant level of involvement. Medical co-morbidities were seen in 18 (25.7%) patients. A significant neurological deficit was seen in 32 (45.7%) patients. At follow up patients were assessed for healing of disease, bony fuson, and clinical outcome was assessed using Macnabs criteria. Results Final follow up was done on 64 (91.4%) patients at a mean average of 25 months (range, 12 to 110 months). Pathologic organisms could be identified in 42 (60%) patients. Forty two (60%) patients had histopathological findings consistent with tuberculosis. Thirty of 32 (93.7%) patients showed neurological recovery. The surgical wound healed uneventfully in 67 (95.7%) patients. Bony fusion was seen in 60 (93.7%) patients. At final follow up healing of infection was seen in all patients. As per Macnabs criteria 61 (95.3%) patients reported a good to excellent outcome. Conclusions Inspite of the theoretical risks, titanium cages are a suitable alternative to autologous tricortical iliac crest bone graft in patients with active spinal infections.

Extended Posterior Circumferential Approach to Thoracic and Thoracolumbar Spine

ObjectivePosterior spinal surgical approach to achieve a retropleural/ retroperitoneal corpectomy with circumferential spinal cord decompression following subtotal vertebrectomy, posterior instrumentation and interbody spacer placement under compression as well as kyphosis correction with spinal column shortening.IndicationsInfective, traumatic or neoplastic lesions of the vertebral body that lead to vertebral body destruction, instability and neurologic deficit.Need for immediate postoperative loading stability to permit ambulation and rehabilitation.ContraindicationsMultiple contiguous vertebral disease.Instances where the graft bed preparation and stable interbody spacer placement may be suboptimal due to the limited access offered by this approach.Surgical TechniquePosterior midline exposure two to three levels above and below lesion, dissection at level of lesion extended bilaterally exposing transverse processes, costotransverse articulations and medial 5–8 cm of ribs. Placement of pedicle screws at proximal and distal levels; in case of osteoporotic bone augment screws with cement. Bilateral costotransversectomy at one or more levels to drain prevertebral abscess and expose diseased vertebral bodies. After temporary stabilization, laminectomy and corpectomy are carried out from both sides to permit circumferential decompression. A temporary rod is placed on the contralateral side in the position of deformity to prevent any inadvertent translatory movements during the subsequent surgical step. After completion of the procedure an appropriately contoured rod is placed. The interbody spacer is positioned. Kyphosis correction by spinal column shortening and compression along the posterior implant is performed.Postoperative ManagementBy day 3 ambulation and rehabilitation are initiated.Results22 patients were operated in the last 8 years with tuberculosis (18 patients – twelve paraplegics), osteoporotic fractures (two patients), congenital kyphosis and Ewing’s sarcoma (one patient each). All patients were followed up at 3, 6, 9, and 12 months and then annually. At each followup, clinical, hematologic and radiologic parameters were assessed. All interbody grafts and cages incorporated without significant loss of correction. Ten of twelve tuberculous paraplegics recovered. No patient had postoperative infection, interbody spacer- or implant-related complications.ZusammenfassungOperationszielDorsaler Zugang zur Wirbelsäule zur retropleuralen oder retroperitonealen Korpektomie mit vollständiger zirkulärer Rückenmarkdekompression nach subtotaler Vertebrektomie, dorsaler Instrumentierung und Einbringen eines intervertebralen Platzhalters unter Kompression sowie zur Kyphosekorrektur mit Verkürzung der Wirbelsäule.IndikationenInfektiöse, traumatische oder neoplastische Läsionen, welche zu Wirbelkörperdestruktion, Instabilität und neurologischem Defizit führen.Notwendigkeit einer unmittelbaren postoperativen Belastung, um Mobilisierung und Rehabilitation zu gestatten.KontraindikationenErkrankung oder Verletzung multipler kontinuierlicher Wirbelsegmente.Situationen, in denen wegen des beschränkten Zugangs eine nicht ausreichende Darstellung der Deckplatten zu erwarten ist und dadurch die stabile Platzierung des intervertebralen Platzhalters erschwert wird.OperationstechnikDorsaler Hautschnitt über zwei bis drei Wirbelsegmente ober- und unterhalb der Läsion. Darstellung beider Querfortsätze bilateral auf Höhe der Läsion, der kostotransversalen Gelenke und der anschließenden 5–8 cm der Rippen. Platzierung von Pedikelschrauben in den proximalen und distalen Segmenten. Bei osteoporotischem Knochen Augmentation der Schrauben mit Zement. Bilaterale Kostotransversektomie auf einer oder mehreren Höhen zur Drainage prävertebraler Abzesse oder zur Darstellung erkrankter Wirbelkörper. Nach temporärer Stabilisation werden Laminektomie und Korpektomie beidseits durchgeführt, um eine zirkuläre Dekompression des Rückenmarks zu gestatten. Ein temporärer Stab wird auf der kontralateralen Seite der Deformität platziert, um intraoperativ unbeabsichtigte translatorische Bewegungen zu vermeiden. Am Operationsende wird dann ein angemessen vorgebogener Stab platziert. Der interkorporelle Platzhalter wird positioniert. Die Korrektur der Kyphose wird durch Verkürzung der Wirbelsäule und Kompression entlang dem posterioren Implantat erreicht.WeiterbehandlungMobilisierung und Rehabilitation ab dem 3. postoperativen Tag.Ergebnisse22 Patienten wurden in den letzten 8 Jahren wegen Tuberkulose (18 Patienten – zwölf Paraplegiker), osteoporotischer Fraktur (zwei Patienten), kongenitaler Kyphose und Ewing- Sarkom (je ein Patient) mit o.g. Methode operiert. Die Patienten wurden 3, 6, 9 und 12 Monate postoperativ sowie anschließend jährlich nachuntersucht, und der klinische, hämatologische und radiologische Verlauf wurde erhoben. Alle interkorporellen Transplantate und Implantate heilten ohne wesentlichen Korrekturverlust ein. Zehn der zwölf tuberkulösen Paraplegiker erholten sich neurologisch. Kein Patient entwickelte eine postoperative Infektion. Postoperative Probleme mit Platzhalter oder Implantat traten ebenfalls nicht auf.

Methicillin-resistant Staphylococcus aureus as a cause of lumbar facet joint septic arthritis: a report of two cases.

Hematogenous septic arthritis of the lumbar facet is a well-recognized although rare1-5 primary infectious entity of the spine. Traditionally, the most commonly implicated organism has been Staphylococcus aureus1,2,6 . Although there have been reports of methicillin-resistant Staphylococcus aureus (MRSA) spondylodiscitis7, methicillin-resistant Staphylococcus aureus as a cause of hematogenous facet joint septic arthritis has not been described, to our knowledge. We report our experience with the treatment of two cases of facet joint septic arthritis due to methicillin-resistant Staphylococcus aureus . The patients were informed that data concerning these cases would be submitted for publication, and they consented. Case 1. A fifty-three-year-old man presented with an eighteen-day history of severe back pain radiating to the left lower limb. He was unable to walk because of the intensity of pain. He had retention of urine, for which he required catheterization. Apart from being a chronic smoker, he had no medical comorbidities. Clinical examination revealed severe tenderness over the left side of the lower back. Neurological examination of the left lower extremity revealed grade-2 (of 5) strength of the extensor hallucis longus and tibialis anterior muscles. Lower extremity sensation and deep tendon reflexes were normal. Rectal examination revealed a lax anal sphincter and an absent bulbocavernosus reflex. Hematological examination showed an erythrocyte sedimentation rate of 77 mm/hr (normal, 6 to 12 mm/hr), a total white blood-cell count of 17.4 × 109/L (normal, 4.3 to 10.8 × 109/L), and a C-reactive protein level of 60 mg/L (normal, <6 mg/L). Plain radiographs were unremarkable. Magnetic resonance imaging demonstrated altered signal intensity in the left L4-L5 facet joint, with fluid causing widening of the joint and extending into the adjacent left paraspinal and psoas muscles (Fig. 1-A). The paraspinal muscle fluid …

Salmonella spondylodiscitis in the immunocompetent: our experience with eleven patients.

Study Design. Retrospective case series. Objective. To report the clinical features, diagnostic dilemmas and management options of 11 immunologically normal patients with salmonella spondylodiscitis. Summary of Background Data. Majority of existing data on salmonella spondylodiscitis in the immunologically normal patient is from anecdotal case report. Methods. From 1995 to 2008, 11 patients with salmonella spondylodiscitis proven by positive culture, biopsy, and Widal test were included. One patient died, and the average follow-up of the remaining 10 patients was 36 months (12-122 months). Five (50%) patients had a documented history of typhoid fever. Intravenous antibiotics for 2 weeks and oral antibiotics for at least 10 weeks were given to all patients. Indications for surgical intervention were unrelenting pain and osseous instability. Clinical outcome was evaluated according to Macnab criteria. Results. Salmonella typhi was cultured in 4 and S. Paratyphi in 5 patients. No organism was identified in 2 patients, on whom the diagnosis was performed by a characteristic history, high Widal titers, and a positive biopsy. Widal titers were positive for all patients (Average + 1360). Five patients were managed with antibiotics only, 1 with surgical debridement and uninstrumented fusion and 4 with single-stage debridement, anterior fusion, and posterior instrumentation. Healing of disease with a good to excellent outcome was seen in all patients. Conclusion. Salmonella and tuberculous spondylitis must be differentiated as they both have similar epidemiological and clinicoradiologic presentations. Prodromal gastrointestinal symptoms are usually not present. The diagnosis rests largely on the recovery of the organism by appropriate culture techniques. However, when this is not apparent the Widal test, in the setting of a suggestive history and radiograph, may be used as a diagnosis tool. Though antibiotics are the mainstay of treatment, surgical debridement with the use of instrumentation may be indicated in selected patients.

Telangiectatic osteosarcoma of the spine: a case report

Telangiectatic osteosarcoma (TOS) of the spine is rare accounting for only 0.08% of all primary osteosarcomas. Though a well described radio-pathological entity it is not often thought of as a cause of paraplegia. We describe the clinical, radiological and pathological features and discuss the treatment options of telangiectatic osteosarcoma of the dorsal spine presenting in a young man. The diagnostic pitfalls are discussed emphasising the fact that the diagnosis of TOS of the spine requires not only a multi modal approach of appropriate radiological and pathological tests but also an awareness of this condition.

Adjuvante dorsale Stabilisierung der thorakalen und lumbalen Wirbelsäule bei tuberkulöser Spondylitis

ZusammenfassungOperationszielDorsale Stabilisierung der Wirbelsäule zur Frühmobilisation, Verkürzung des Krankenhausaufenthalts und Aufrechterhaltung der vorgenommenen Korrektur nach vorangegangenen Débridement und ventraler Knochenblocktransplantation bei tuberkulöser Spondylitis.IndikationenTuberkulöse Spondylitis, die eine ventrale Drainage, ein Débridement und eine Dekompression sowie eine Wirbelkörperfusion erfordert.Größerer Knochenverlust eines Wirbelkörpers.Kyphose über 25°.Begleitende Zerstörung der hinteren Säule.KontraindikationenSchlechter Allgemeinzustand, der eine so belastende Operation verbietet.Superinfektion einer tuberkulösen Fistel am Rücken.OperationstechnikDer erste Schritt besteht aus dem ventralen Débridement und einer Knochentransplantation. Dorsale Stabilisierung, vorzugsweise während derselben Operationssitzung, in Höhe der thorakalen Wirbelsäule und bei allen Patienten mit Osteoporose. Ungeachtet der Höhe des Herdes wird eine Rahmenfixation über sublaminare Drahtschlingen nach Hartshill bevorzugt. In Höhe der lumbalen Wirbelsäule wird bei fehlender Osteoporose die Plattenosteosynthese nach Steffee unter Verwendung transpedikulärer Schrauben bevorzugt.ErgebnisseZwischen Juni 1993 und Dezember 1996 wurden 25 Patienten (neun Männer, 16 Frauen, Durchschnittsalter 38,5 Jahre) mit tuberkulöser Spondylitis operiert. Durchschnittliche Nachuntersuchungszeit 16,9 Monate. Präoperative neurologische Ausfälle bei 15 Patienten persistierten nur zweimal. Der durchschnittliche Korrekturverlust lag bei 6,5°. Die durchschnittliche Dauer bis zur Fusion betrug 6 Monate. Ein Materialversagen wurde nicht beobachtet. Bei einem Patienten kam es infolge einer Infektion zum Ausriss einer Schraube. Bei einem Patienten trat vorübergehend eine neurologische Störung auf.AbstractObjectivePosterior instrumentation and stabilization allowing early mobilization, shortened hospital stay and maintenance of correction after debridement and bone grafting for tuberculous spondylitis through an anterior approach.IndicationsTuberculous spondylitis requiring anterior drainage, debridement and decompression, as well as interbody fusion.Significant bone loss of vertebral body.Kyphosis > 25°.Concomitant posterior column disease.ContraindicationsPoor general health precluding such an extensive intervention.Superinfection of tuberculous sinus on the back.Surgical TechniqueThe first stage consists of anterior debridement and bone grafting. During the second stage, preferably performed at the same sitting, a posterior stabilization is done. At the level of the thoracic spine and for all patients with osteoporosis irrespective of the level, a sublaminar wiring (Hartshill) is performed. At the lumbar spine pedicular screw fixation and Steffee plating are done in the absence of osteoporosis.ResultsBetween June 1993 and December 1996 25 patients (nine men, 16 women, average age 38.5 years) with tuberculous spondylitis underwent this two-stage procedure. Average length of follow-up 16.9 months. A preoperative neurologic deficit seen in 15 patients persisted only in two. The overall loss of correction amounted to 6.5°. The average time to fusion was 6 months. No implant failures were recorded. A screw pull-out secondary to infection accompanied by loss of correction occurred in one patient. Another patient experienced a transient neurologic deficit.

Chondrosarcoma of the Spinous Process: A Rare Presentation

Chondrosarcomas are malignant cartilage forming tumours. They form the second most common primary malignant tumour involving the vertebral axis. We present a rare presentation of a secondary chondrosarcoma from the spinous process of lumbar vertebra and discussed its management. The main emphasis is on the rare presentation and the need for awareness and suspicion of the pathology.